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A pharmacist’s perspective on prior authorizations

Have you ever been to the pharmacy and the technician tells you that your medication is not ready for pickup because it requires a prior authorization (PA)? As a pharmacist, I often have the unfortunate duty of breaking the news that not all medications are initially covered by insurance. I am frequently asked about all the details that involve working through a PA, such as “How long is it going to be until my prescription is ready?” and “How much is this going to cost?”

When explaining PAs to patients, I share with them that the medication prescribed is not a preferred medication on their insurance’s formulary plan and requires additional steps to determine if the medication will be covered at all. Due to the cost to both the pharmacy and the patient, this rigorous process to determine medical necessity is in place to assist with getting the medications covered at a reasonable price.

While PAs are used to keep cost down, they can hinder patients’ ability to stay adherent on their medications. In some cases, a lack of a PA can prevent the patient from getting a medication in a timely manner and can lead to additional costs from emergency department visits, or even hospitalizations.

PAs are frustrating for all that are involved, especially physicians. According to a 2010 American Medical Association survey, physicians spend an average of 20 hours per week on PA activities. It is astonishing to think that half of a traditional work week goes into dealing with the hassle of PAs. With an estimated 835,000 practicing physicians in the U.S., it translates to 868 million hours spent on PAs by physicians alone.

In addition to the time spent on PAs, a Health Affairs study found that other estimated costs – such as nurse wages, telephone line, fax machine – means the annual average cost per physician of interacting with insurance plans is $83,000. And here’s the scary part – these numbers are constantly on the rise, as more insurance companies are adding medications to the PA list. Ultimately, the extra time and money spent on dealing with PAs could be dedicated to increasing the quality of patient care.

What I find most interesting about this process is that the medication could help prevent additional cost to patients, providers and pharmacists, both in the form of time and money – but it ends up doing the opposite.  So, the big question is: how do you make the PA process easy for the provider and patient to not only prevent high costs, but to save time?

Technology will be a big part of the solution. If providers can initiate a PA within their current electronic prescribing workflow, it will ultimately save time, money and resources. As a clinical pharmacist, I fully embrace cost- and time-saving solutions that help all levels of healthcare professionals in the field with their daily activities. Processing PAs more efficiently helps patients get the medication they need to stay healthy, and it enables physicians and pharmacists to spend time with other patient-related activities. 

Allscripts eAuth™ is our PA solution, and it is now available for three Allscripts platforms (ePrescribe standalone, Allscripts Touchworks® EHR, and Allscripts Professional EHR™). To learn more about eAuth, clients can visit our Client Connect page

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